SHM Converge Scientific Abstract ePoster Gallery-Beneath the Surface: A Case of Bactrim-Triggered Erythrodermic Psoriasis

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This case describes a 35-year-old man with juvenile rheumatoid arthritis, contractures, and chronic psoriasis who developed erythrodermic psoriasis (EP) after treatment with trimethoprim-sulfamethoxazole (TMP-SMX) for MRSA/MSSA bacteremia. Several days after discharge, he presented with neck and axillary pain, diffuse erythema, and a positive Nikolsky sign. The main differential diagnosis was staphylococcal scalded skin syndrome versus severe EP triggered by TMP-SMX.<br /><br />TMP-SMX was stopped immediately, and the patient was started on intravenous antibiotics and steroids. His erythema and pain improved quickly. Infectious Disease had low concern for staphylococcal scalded skin syndrome, and Dermatology confirmed EP. He was then treated with methotrexate and folate, followed by a very slow oral steroid taper and outpatient follow-up.<br /><br />The report emphasizes that psoriasis can rarely progress to erythrodermic psoriasis, a dangerous inflammatory state involving widespread skin involvement, systemic symptoms, and potential disruption of thermoregulation and metabolism. EP results from complex interactions among environmental, genetic, skin, and immune factors, leading to T-cell activation and keratinocyte overproduction. In high-risk patients, TMP-SMX may act as a trigger, especially in those with underlying rheumatologic and dermatologic disease.<br /><br />First-line EP treatments include cyclosporine, infliximab, and methotrexate, with biologics used in more severe or refractory cases. Although steroid use in psoriasis is controversial, short courses may be helpful when combined with immunosuppressive therapy in selected patients.<br /><br />Overall, this case highlights EP as a rare dermatologic emergency requiring rapid recognition, prompt discontinuation of potential triggers, and immediate treatment.

Asset Subtitle

Anastasia Bury

Meta Tag

Author List Anastasia Bury, Priyanka Hirlekar, Ryan C. Crane

Category Clinical Vignettes

Concept Erythrodermic Psoriasis

Concept Erythema

Concept Total Body Surface Area

Concept Pruritus

Concept Pain

Distinguished Non-Finalist

Presenter Organization Corewell Health Grand Rapids

Presenting Author Anastasia Bury

Track Adult

Keywords

erythrodermic psoriasis

trimethoprim-sulfamethoxazole

TMP-SMX

juvenile rheumatoid arthritis

staphylococcal scalded skin syndrome

MRSA bacteremia

Nikolsky sign

methotrexate

psoriasis flare

dermatologic emergency

Erythrodermic Psoriasis

Erythema

Total Body Surface Area

Pruritus

Pain